Correctional Mental Health:
Best Practices: What Works?
Presentation to the
2015 Ninth Circuit Corrections Summit
Robert L Trestman PhD MD

Professor of Medicine, Psychiatry, and Nursing
Executive Director, Correctional Managed Health Care
Interim Director, Center for Public Health and Health Policy
UConn Health
Farmington CT

AGENDA
1) Best practice and guidelines
2) Implementation science
3) Suicide risk reduction
4) Psychotherapy
5) Pharmacology
6) Community Transitions
7) Academic partnerships

1: Principles Governing the
Delivery of Psychiatric Services
2: Guidelines for Psychiatric
Services
3: Special Applications of the
Principles and Guidelines

• Community Standard:
“what the community
should be providing. . .”
• Staffing- adequate to
provide services
• Culture
– Therapeutic vs
retributive

IMPLEMENTATION SCIENCE
Exploration

Preparation

Adm Policy Ment Health (2011) 38:4–23 7

Implementation

Sustainment

1) IMPLEMENTATION SCIENCE IN CORRECTIONAL
MENTAL HEALTH

OUTER CONTEXT
Sociopolitical
Leadership
Policies
initiatives, settlements, decrees
Funding
Public-academic collaboration

1) IMPLEMENTATION SCIENCE IN CORRECTIONAL
MENTAL HEALTH
INNER CONTEXT
Organizational characteristics
Leadership
Embedded EBP culture
Critical mass of EBP provision
Social network support
Fidelity monitoring/ support
EBP role clarity
Fidelity support system
Supportive coaching
Staffing
Staff selection criteria
Validated selection procedures

SUICIDE RISK
REDUCTION

• Culture
• Screening- admission and at
times of high stress
• Assessment
• Treatment
• Physical plant issues
• Non-punitive suicidal ideation
management
• Supervision / Quality
Assurance
• High Risk : Restricted Housing
Environments

PSYCHOTHERAPY

• Cognitive Behavioral
Therapies
• Manual-Guided, Clinician
Driven
• Evidence of Benefit:
– Moral Reconation
Therapy
– Reasoning and
Rehabilitation
– STEPPS
– START NOW

• Developed for offenders with behavioral disorders
• NIJ funded development
• Public domain materials

Connecticut
Maine
New Jersey
New York
(training begins March 2016)
Kersten, Linda, et al. Psychiatric Services (2015): appi-ps.

PHARMACOLOGY
• Current community medications may have been
determined while ongoing illicit drug use confounded
diagnosis
• Collaboration between clinician and patient may
have been poor; treatment adherence may in turn
have been marginal.
• Patients with schizophrenia: 29% non-adherent, with
substance abuse a significant risk factor

Baillargeon, J. et al. (2010). Admin & Policy in Mental Health and Mental Health Services Research, 37(4):367-374.
Novick, D., et al. (2010). Psychiatry Research, 176(2):109-113.
Mojtabai R, Olfson M. (2010). Archives of General Psychiatry. 67(1):26-36.

• Advantage of correctional psychiatry: opportunity to
observe the functioning of a patient in a safe,
monitored environment
• When diagnostic ambiguity exists, appropriate
tapering off of community medications can be
conducted with greater safety and collateral
information than achievable elsewhere.
• Very little evidence that several drugs are ever better
than one

Trestman R. Transition of pharmacology from community to corrections. In Trestman RL, Appelbaum KL, Metzner JL (Eds), Oxford
Textbook of Correctional Psychiatry, Chapter 19, 2015.
Tiihonen, J., et al. (2012). Archives of General Psychiatry, 69(5):476-483

These drugs may be abused for their
sedative properties, mind altering effects,
or for the potential to get a high
– pulverized & snorted or IV

RISK:
ABUSE OF
PRESCRIBED • bupropion (Wellbutrin)
MEDICATION • gabapentin (Neurontin)

• quetiapine (Seroquel):
– “quell”, “Susie Q” , “Q-ball”, or “baby
heroin”
•
•
•
•
•

Reccoppa L , Malcolm R , Ware M. Gabapentin abuse in inmates with prior history of cocaine dependence.
Am J Addict. 2004;13(3):321–3.
Pierre JM , Shnayder I , Wirshing DA , Wirshing WC. Am J Psychiatry. 2004;161(9):1718.
Waters BM , Joshi KG. Am J Psychiatry. 2007;164(1):173–4.
Pinta ER , Taylor RE. Quetiapine addiction?. Am J Psychiatry. 2007;164(1):174–5.
Hanley MJ , Kenna GA. Am J Health Syst Pharm. 2008;65(7):611–8.

COMMUNITY CONTINUITY
• Education and engagement
• Reduce pill burden: Once daily dosing when possible
• Transition back to the community
– Medicaid continuity/ enrollment
– Clinical connection: in-reach and out-reach
Kesten KL, et al. Journal of Correctional Health Care, 2012, 18(1):20-8.
Trestman RL, Aseltine RH. Perspectives in Health Information Management. 2014 Winter; 11(Winter): 1e.

Mortality Rates among Former Inmates of the
Washington State Department of Corrections during the
Study Follow-up (Overall) and According to 2-Week
Periods after Release from Prison.

BINSWANGER IA ET AL. N ENGL J MED 2007;356:157-165.

ACADEMIC
PARTNERSHIPS

• Research and evaluation
• Training and recruitment
• Enhanced employee
engagement and morale